Periodic Survey #28 Lead Screening Practices of Pediatricians

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PERIODIC SURVEY OF FELLOWS
American Academy of Pediatrics
Division of Child Health Research

EXECUTIVE SUMMARY

This report presents findings from Periodic Survey #28
which explored the current lead screening practices of pediatricians,
their opinions regarding issues surrounding lead screening, as well
as their attitude toward the AAP/CDC recommendations on lead screening.
This topic was initiated by James Campbell, MD, a researcher from the
University of Rochester, NY; the survey was developed in collaboration
with the AAP Committee on Environmental Health.

PS #28 was an eight-page self-administered questionnaire
sent to a random sample of 1,610 active US FAAPs. The original mailing
and four follow-up mailings to recontact nonrespondents were conducted
from November 1994 to February 1995. After five mailings we received
a total of 1035 completed questionnaires for a response rate of 64.3%.
The questions on this survey were addressed primarily to the 734 pediatricians
who provide preventive care to children £
36 months of age (71% of the respondents).

Screening for Lead Poisoning:

The majority of pediatricians screen their patients £
36 months of age for lead poisoning.

53% of pediatricians attempt to screen ALL of their patients £
36 months of age with a blood test for lead toxicity, 38% attempt
to screen SOME of their patients, while 9% screen NONE of their
patients in this age group.

Screening practices vary by practice location: 83% of inner city
pediatricians screen ALL of their patients £
36 months of age for lead poisoning, compared to 50% of other urban
pediatricians, 39% of suburban and 43% of rural pediatricians (p<.001).

Overall, pediatricians attempt to screen about one-half of their
patients age 9-24 months for lead poisoning: pediatricians report
screening an average of 52% of their 9-12 months olds, 48% of their
13-14 month olds, and 37% of their patients aged 25-36 months.

Among pediatricians who selectively screen their patients,
almost all screen children whose parents request lead screening and
children in high-risk groups; the average age at which they begin to
screen high-risk patients is 9.7 months

98% of pediatricians who selectively screen patients £
36 months of age report do so at the parents' request. Nearly all
pediatricians (97%) also screen children of this age who have a
history of pica, who live in or regularly visit an older home that
has peeling or chipping paint (95%), whose sibling has an elevated
lead level (95%), who lives in an older home that has recent renovations
(93%), or who live near an industry that releases lead (93%), are
enrolled in Medicaid (93%), whose parents use lead compounds in
a hobby or occupation (92%), and who have a past history of toxic
ingestion (90%).

The primary reason given by pediatricians for not universally
screening their patients for lead poisoning is prevalence of low lead
levels among the children in their practice.

90% of pediatricians who do not universally screen (including
those who do not screen any of) their patients £
36 months of age say they do not do so because of the low prevalence
of venous lead levels ³ 10mcg/dl
among their patients. About one-third of pediatricians who selectively
screen for lead poisoning say lead screening is too costly (33%)
and that other issues are more important to review with parents
(34%).

Screening Practices

The data in this section are limited to the 91% (666)
respondents who screen some or all of their patients £
36 months of age for lead poisoning.

Forty-one percent of pediatricians who screen for lead
poisoning use a lead poisoning risk-assessment questionnaire designed
to identify children at greater risk of lead exposure; two-thirds of
these pediatricians (64%) use the questionnaire to focus education on
parents and 60% do so to decide whether to screen.

Nearly all pediatricians (96%) use the blood lead level
test to screen for lead poisoning; 2% use erythrocyte protoporphyrin
level test. One-half (52%) use venipuncture to collect blood for screening
and 39% use fingerstick. All pediatricians (99%) usually screen for
lead poisoning at well-child visits; however, 48% say they screen at
follow-up chronic illness visits and 40% screen at follow-up acute illness
visits.

Slightly more than one-third of pediatricians (37%) say
their lead screening practices have changed with the last 24 months;
most (55%) of these pediatricians say they have increased the number
of patients screened and increased the frequency with which patients
are screened (49%), while 41% say they just began to screen for lead
poisoning. These changes are primarily due to the AAP recommendations
(62% of these pediatricians so reported) and CDC recommendations (45%
so reported).

Most pediatricians (52%) have read the 1991 CDC statement
on lead poisoning and 61% have read the 1993 AAP statement on lead poisoning;
most of the balance are aware that statements on lead poisoning exist,
but they have not read them. One-third of pediatricians (33%) say they
are aware of local or state laws that require them to screen children
for lead poisoning; although nearly as many (28%) do not know if such
laws exist.

Lead Poisoning Education/Services Available

Most pediatricians who screen for lead poisoning (67%)
say either they or other medical personnel in their office provide education
on the sources and effects of lead before they perform lead screening.

63% of pediatricians who screen for lead poisoning usually provide
parents with lead screening information before screening their patients;
37% provide such information after screening for lead poisoning
when their patients blood level is 10.6 mcg/dl or higher.

Three-fourths of pediatricians say lead poisoning information
is delivered by them or by other medical personnel (77% of pediatricians
so reported) and by printed material (75% so reported). Nearly all
pediatricians say the information covers sources of lead (99%) as
well as the effects of lead (91%).

39% of pediatricians who screen for lead poisoning say there is
a center in their community (other than their state or local health
department) that specializes in the treatment of lead poisoning
where children with lead poisoning can be referred for various services,
37% say there is no such center available, and 24% do not know.

Most of the 734 pediatricians who provide well child care
to children £ 36 months old are aware
of state or local health department provides services for children who
have lead poisoning , 30% do not know of such services.

Nearly two-thirds of all pediatricians who provide well child
care to children £ 36 months old
(64%) report that their state or local health department provides
services for children who have lead poisoning, 30% do not know of
such services.

Opinions Regarding Lead Screening

Most pediatricians (73%) agree 10mcg/dl is the lowest
lead level that should be considered elevated. They believe elevated
lead levels are a common problem only among inner-city and other high-risk
groups of children. Many are unsure about the benefits of universal
screening; most all would like to have epidemiologic studies performed
to determine high-risk communities.

79% of pediatricians think lead levels ³
10 mcg/dl among children 9-36 months old are a common problem in
US urban inner cities. Only 20% think this lead level is commonly
found in suburban children, while 29% are unsure. One-forth (24%)
of pediatricians agree and 38% are unsure as to whether lead levels
³ 10 mcg/dl are common in US rural
communities.

Overall, most pediatricians (67%) do not think lead levels ³
10 mcg/dl are common in their practice. However, this varies substantially
by location: 85% of pediatricians practicing in suburban areas,
74% of those in urban, inner-city pediatricians do not believe lead
levels ³ 10mcg/dl are common in
their practice areas (p<.001). Two-thirds of pediatricians describe
their primary practice area as urban, not inner-city or suburban,
while 28% describe their practice area as urban, inner-city.

60% of pediatricians believe children £
12 months of age are at risk for lead levels between 10-19 mcg/dl;
25% are unsure.

Most pediatricians (64%) agree Head Start programs should require
lead screening for enrollment. However, their opinion is divided
on whether daycare centers should require lead screening for program
enrollment (37% agree, 37% disagree, and 25% are unsure).

59% of pediatricians believe that interventions for children 9-36
months of age who have lead levels between 10-19 mcg/dl are effective
in reducing lead levels.

The majority of pediatricians (90%) think epidemiologic studies
should be performed to determine which communities have significant
proportions of children who have elevated lead levels.

Pediatricians are evenly divided on their opinion regarding whether
the benefits of universal screening for lead exposure for children
9-36 months of age outweigh its costs (38% agree, 35% disagree,
and 28% are unsure)